Provider Demographics
NPI:1255986618
Name:MODHA, JIGNESH BHIKHALAL (DDS)
Entity type:Individual
Prefix:
First Name:JIGNESH
Middle Name:BHIKHALAL
Last Name:MODHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721-8904
Mailing Address - Country:US
Mailing Address - Phone:570-753-5403
Mailing Address - Fax:
Practice Address - Street 1:107 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AVIS
Practice Address - State:PA
Practice Address - Zip Code:17721-8904
Practice Address - Country:US
Practice Address - Phone:570-753-5403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist